Are transfusions the holy grail? Don't take it as read

"IT TAKES someone special to give blood" says the Australian Red
Cross Blood Service's slogan  which makes 500,000 Australians
every year quite special. But could their altruism be
misplaced?

The answer, according to American cardiothoracic specialist
Bruce Spiess, may well be yes. During last week's annual scientific
meeting of the Australian and New Zealand College of Anaesthetists,
Professor Spiess, from the Virginia Commonwealth University, poured
scorn on the belief that blood, or at least the transfusion of it,
was the elixir of life.

"Blood transfusions are a religion. They have never been safety
or efficacy tested," he said. "Drug options are carefully tested
and regulated through prospective, randomised double-blind testing,
but blood transfusion stands apart in that it has predominantly
been believed to be helpful and evolved as a pillar of modern
medicine."

Professor Spiess cited a Swedish study involving Jehovah's
Witnesses, whose religion forbids them to accept transfusions. It
showed that 499 Witnesses who had open-heart surgery had better
survival rates than other open-heart patients.

The problem with transfusions is not transmission of diseases
such as HIV or hepatitis, which are screened for by blood banks,
but post-operative complications such as pneumonia, wound infection
and organ failure, some of which can be fatal.

Blood transfusions could indeed cause "major morbidity or even
mortality", said Professor James Isbister, of the University of
Sydney. "Increasingly, evidence and experience is suggesting that
blood banking and transfusions medicine have excessively focused on
supply rather than the demand/patient perspective."

Because blood is given free, it is a cheap alternative to
treatments such as drugs. A statement from the Australian and New
Zealand College of Anaesthetists said: "In Australia, the economics
of blood discourages the use of alternatives because Australians
donate blood and the Red Cross gives it to hospitals free
alternatives to transfusion include minimising blood loss and
maximising oxygenation."

Professor Spiess told the conference of anaesthetists  the
profession responsible for half the transfusions associated with
surgery  that campaigns to encourage blood donation had
helped shape the notion that all transfusions were good. Women
received more transfusions than men, with worse outcomes from heart
surgery a particular problem.

The Australian Red Cross Blood Service, which administers the
nation's blood banks, referred The Sunday Age to Larry
McNichol, head of anaesthesia at the Austin Hospital. Dr McNichol,
who is also chairman of a Department of Human Services committee on
transfusions, said his friends were "gobsmacked" when he told them
about the problems with blood.

"They were saying, 'How can you say blood isn't fantastic, it
saves people's lives'," he said.

"It is fantastic, it's a gift and it's saved lots of lives. But
it's also important to realise that for everything there is a
side-effect. It's just that it's taken us a long time to start
building up the evidence for the potential adverse effects of
having a transfusion."

Transfusion is needed when hemoglobin  the
oxygen-containing protein in red blood cells  falls below a
certain level, endangering the body's ability to transport oxygen.
But the level at which transfusion is required, said Dr McNichol,
is debatable.

"We were always taught that if (hemoglobin) drops below 10
(grams per deci-litre) you should perhaps give (the patient) some
blood. What we're really saying, and Bruce Spiess articulated it
really well, is that there is no scientific basis for the figure of
10. Somebody just said, it sounds around about the right
figure."

There is evidence, said Dr McNichol, that some anaesthetists
were giving blood when the count fell as low as seven. In general,
the right level depended on the patient's condition.

For Jehovah's Witnesses in surgery, there is a range of
strategies. Drugs can be taken that boost hemoglobin, reducing the
need for transfusion or reducing surgical bleeding. During some
forms of surgery, the patient's blood can be collected, washed, and
pumped back into the body.

There are also ways to treat blood so it becomes less likely to
cause side-effects. One is the removal of white blood cells. The
other is bacterial testing of platelet bags. Both measures have
received federal funding, bringing Australia into line with
Britain, Europe, Canada and most of the US. Despite such measures,
the growing consensus is: transfuse only when necessary.

"It's not an insignificant thing to have to give a patient a
unit or two of blood because these things can be bad for you," Dr
McNichol said. "What the emphasis is on now is saying what can we
at the clinical coalface do to minimise the chances of patients
having to have blood."

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